Torrent of new audits and auditors underscores need for provider proactivity in 2016
By Dawn Crump, MA, SSBB, CHC, Vice President, Audit Management Solutions, CIOX Health
Twitter: @CIOXHealth
Like the heavy rains, flooding and snowstorms experienced early this year, a deluge of audits is putting hospitals and health systems in a potentially precarious situation. New audits and activity is already underway.
In order to minimize takebacks, it is imperative that healthcare providers adequately educate themselves and plan ahead for the plethora of audits ahead—old and new.
RAC activity on the rise
In December of 2015, CMS announced its plan to increase Medicare’s Recovery Audit Contractor (RAC) program in several ways. Audits of Medicare Advantage plans will be expanded with the goal of preventing insurers from obtaining higher payments than rightfully due. Medicare’s RAC program will also be extended to include Part D plans, but a timeline for this has not yet been set.
As part of the expansion of the program, Medicare Advantage RACs will conduct reviews similar to risk adjustment data validation (RADV) reviews. CMS pays a variable amount each month to each Medicare Advantage insurer for every member it covers. The amounts are variable because they are based on risk-adjusted scores. Auditors will ascertain whether an insurance company’s risk scores are jibing with the data they collect.
RACs will also engage in “condition-specific” RADV audits, which focus on specific conditions and/or diagnostic codes that tend to have high rates of errors in payment. Although CMS currently conducts RADV audits on only about five percent of its Medicare Advantage contracts, the eventual goal is to subject all contracts to a RADV audit each year.
In addition to maintaining vigilance where RACs are concerned, providers should be tracking QIOs, which are now auditing for Two Midnight Rule compliance.
QIO audits of Two Midnight Rule
CMS also announced revisions to Chapter 5 of the Quality Improvement Organization (QIO) Manual, which addresses quality of care reviews. The announcement was made in August 2015 and goes into effect this year.
“A Quality Improvement Organization (QIO) is a group of health-quality experts, clinicians and consumers organized to improve the care delivered to people with Medicare,” CMS states. “QIOs work under the direction of CMS to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.”
According to KEPRO, a Medicare QIO under contract with CMS, the revisions to Chapter 5 include the following changes for certain quality of care concerns:
- Providers will have 14 days (was 30 days) to send in the medical record when a quality of care complaint is filed. Because of these tightened time frames, providers are encouraged to fax medical records to KEPRO rather than sending them via mail.
- After the medical records are received, KEPRO has 30 days to complete the review. Providers that wish to provide a response when they receive an inquiry from KEPRO will also have a shortened time frame, which will be noted on the inquiry letter.
- Medicare beneficiaries, or their representatives, will have the opportunity to request a second review if they disagree with the original findings, similar to the current process in place for providers.
For the Two Midnight Rule, limits on ADR requests (10-30) depend on organization size. Timelines are as follows:
- 45 days to submit record
- Results due back within 30 days
- 6-month look back period
- 1 on 1 verbal education with providers with high error rate
Further complicating the issue are the modifications to the controversial and confusing Two Midnight Rule.
More Modifications to Know
On July 1, 2015, CMS released proposed updates to the Two Midnight Rule, specifically concerning when inpatient admissions are appropriate for payment under Medicare Part A. Beginning on January 1, 2016, QIOs and Recovery Auditors may conduct patient status reviews in accordance with any policy changes finalized in the Outpatient Prospective Payment System (OPPS) rule and effective in calendar year 2016. Recovery Auditors may conduct patient status reviews only for those providers that have been referred by the QIO as exhibiting persistent noncompliance with Medicare payment policies, including high denial rates and repeated failure to adhere to the Two Midnight Rule, or failing to improve performance after QIO educational intervention.
Meanwhile, Recovery Auditors may continue to conduct reviews of short-stay inpatient claims for other reasons, including CMS-approved claim reviews unrelated to patient status. These changes will not affect other reviews such as Comprehensive Error Rate Testing (CERT) reviews for payment errors— Zone Program Integrity Contractor (ZPIC) reviews and OIG efforts specifically looking for fraud, waste and and abuse.
Other audits to watch
Providers should also be aware of audits to health plans. If a health plan is audited by a RAC, negative consequences can easily trickle their way down to the provider.
When it comes to audits regarding health plans, whether conducted by them or to them, providers need to have some questions answered:
- What are they auditing?
- What are they permitted to audit in their contracts with your organization?
- What happens if the health plan gets audited?
Finally, providers should be paying attention to coding audits; RAC Request For Proposals updates; and changes in CMS’ take-back/recoupment process and methodology (how they recover money from providers).
Proactivity, proper planning and education increases your chances of staying dry through this early 2016 audit spate.